Sunday, August 03, 2008

An invitation from the Los Angeles Times Booster Shots blog asking us to join in on an upcoming exploration -- both in print and online via a live chat this Tuesday, August 5 -- of the difficulty many combat veterans face in getting a fitful night's sleep. (Heaven knows writers and other creatives like myself generally fall into the night owl category, too, but our lack of sleep is obviously of the less mentally draining and certainly less alarming sort.)

First, details from the Times, and below the fold you'll find a number of recently related reports that have turned up in the news and clinical journals:

Mitch Hood, 25, spent two tours in Iraq with the Marines. Now, like many other veterans, he faces a new enemy: sleep.

Hood has nightmares nearly every night, many like the one above, laced with the fear he felt when he was in Iraq. Most nights, he battles his own body's need to sleep, opting to stay awake so he doesn't fall into nightmares.

Hood knows he is not the only one with these problems. Sleep and wakefulness issues are the most common health problems described by recently returned soldiers, researchers at Walter Reed Army Medical Center found in a study published last year.

A Times reporter and videographer stayed up all night with the former Marine and his fiancee to witness his struggles. The print story will appear in Tuesday's newspaper. A video of the vigil, plus interviews with Hood and other veterans, accompany the story on the Web.

Join us for a live Web chat at noon Tuesday to discuss the influence of war on sleep and how physicians try to treat the problems. We will be doing a question-and-answer session with Dr. Thomas C. Neylan, director of the Posttraumatic Stress Disorders (PTSD) Program at the San Francisco Veterans Affairs Medical Center, and Steve Woodward, director of the Sleep Research Laboratory at the VA's National Center for Posttraumatic Stress Disorder in Palo Alto.

Just last month, Meghan Cooke filed a related piece in the Fayetteville Observer. After introducing us to Sgt. Rashaun Carpenter, a two-time Iraq vet who had survived a downed-by-Fallujah-insurgents chopper crash only to endure TBI, arm and pelvis injuries and intrusive symptoms of PTSD including endless nightmares of being set on fire, shot and stabbed, Cooke gives us an overview of the dilemma:

[F]or many military personnel and veterans, sleep is hard to come by. Whether they're on the front lines or reliving traumatic memories years after combat, sleep disorders are a growing part of military life. Statistics about the number of military personnel with sleep disorders are difficult to determine because the disorders are often symptoms of other problems, doctors say.

Lt. Col. Scott Johnson, chief of the Department of Medicine at Womack Army Medical Center, said doctors there have seen a significant number of people seeking treatment for sleep problems. Sleep apnea, severe snoring and restless leg syndrome are among some of the common complaints, he said. But some soldiers coming home from Iraq and Afghanistan are experiencing what he described as circadian rhythm disturbance.

People function on a 24-hour cycle known as the circadian rhythm. When soldiers are required to be alert when their bodies are typically asleep, some develop rhythm disturbances. Similar disturbances are also seen in civilian shift workers.

"As you're carrying a M-16 door-to-door, you live on an adrenaline rush," Johnson said. But eventually, they have to crash, he said.

Johnson said soldiers returning from deployment also face the stress of re-entering a non-combat environment. Whether they experience problems reintegrating into their families, alcohol abuse or even post-traumatic stress disorder, sleep issues might arise.

In Carpenter's case, due to his PTSD-related nightmares, he has to find a way to make it through his days running on a couple of hours of sleep a night -- tops.

He attends PTSD support group meetings every week. "Nobody in the group gets more than five hours of sleep, I'd say," he said.

Dr. Jack Edinger, a psychologist at the Durham Veterans Affairs Medical Center and a psychiatric professor at Duke University, said sleep disturbances are a common symptom in PTSD patients. Recovery can include a complex array of treatments when PTSD is involved, he said.

One is imagery reversal therapy, a process by which patients write out their nightmares with a new, positive ending. Then they review it in their minds with the new ending. Edinger said this may reduce the frequency and severity of the nightmare.

In May, the Army released statistics that showed that the number of new PTSD cases increased by 46.4 percent in 2007 from the previous year, bringing the number of diagnoses to nearly 40,000 troops since the war began. ...

Dr. Mary Fruit, chief of mental health at the Fayetteville VA Medical Center, said sleep disorders are often related to other health problems, including PTSD. Some are simply afraid to go to sleep, she said.

"I've had combat veterans say, 'Bad things happen at night,'" she said. "That's when Charlie comes. "If that's something they endure everyday for 12 months, are we surprised they come back with sleep problems?"

Fruit said people can improve sleep by adopting healthy sleep habits, such as setting a regular sleep schedule, avoiding caffeine in the evenings and making the bedroom a calm refuge. But Fruit said few patients seek help who only have problems with sleeping. Doctors often must delve deeper to resolve underlying issues.

"The sleep disruption is so intertwined it's not usually the only thing on the table," Fruit said. "If you're well-rested, you're better able to deal with the other problems.

"The reality is that no one who goes to war is ever the same."

Another example of one veterans' struggle for a peaceful night's rest in last month's Suburban Chicago Daily Herald:

Most times, Jim Black surfs the Internet into the early morning hours. When he does sleep, it's not for long and it's not very restful because of the nightmares.

"They're so vivid," says the 26-year-old Lake Villa resident. "I haven't gotten eight hours of sleep in five years." The nightmares take him back to his time in Iraq, where Black served as a reconnaissance specialist in the Army beginning in 2003, at the dawn of the Iraq War.

"I had a 5-year-old throw a grenade in my truck the second day I was there. My son is 5," Black says matter-of-factly. Listening, as always, is his father-in-law, Tim Corrigan. He's heard a lot the last few years and has tried to help. But he has never been in combat and can't provide what Black needs most: someone who truly understands.

There are many reasons why people with PTSD may have trouble sleeping:

Changes in your brain:PTSD can cause changes in the brain making it difficult to sleep. Many people with PTSD may feel they need to be on guard or "on the lookout," to protect him or herself from danger. It is difficult to have restful sleep when you feel the need to be always alert.

Medical Problems:There are medical problems that are commonly found in people with PTSD such as chronic pain, stomach problems, and pelvic-area problems in women. They physical problems can make going to sleep difficult.

Your Thoughts:Your thoughts can make it difficult to fall asleep. People with PTSD often worry about general problems or worry that they are in danger. If you have not been able to sleep for several nights (or even weeks), you may start to worry that you won't be able to fall asleep. These thoughts can keep you awake.

Drugs or Alcohol:Some people with PTSD use drugs or alcohol to help them cope with their symptoms. Drinking and using drugs can make it more difficult to fall asleep.

Upsetting Dreams or Nightmares:Nightmares are common for people with PTSD. Nightmares can wake you up in the middle of the night, making your sleep less restful. Or, you may find it difficult to fall asleep because you are afraid you might have a nightmare.

Hearing a Noise:Many people with PTSD wake up easily if they hear a noise. You may feel that you need to get up and check your room to make sure you are safe.

Read the rest for valuable tips on coping with sleeplessness. And finally, the April issue of Biological Psychiatry reported:

A generic drug already used by millions of Americans for high blood pressure and prostate problems has been found to improve sleep and lessen trauma nightmares in veterans with posttraumatic stress disorder (PTSD).

"This is the first drug that has been demonstrated effective for PTSD nightmares and sleep disruption," said Murray A. Raskind, MD, executive director of the mental health service at the Veterans Affairs Puget Sound Health Care System and lead author of a study appearing April 15 in Biological Psychiatry.

The randomized trial of 40 veterans compared a nightly dose of prazosin (PRAISE-oh-sin) with placebo over eight weeks. Participants continued to take other prescribed medications over the course of the trial.

At the end of the study, veterans randomized to prazosin reported significantly improved sleep quality, reduced trauma nightmares, a better overall sense of well being, and an improved ability to function.

"These nighttime symptoms are heavily troublesome to veterans," said Raskind, who also is director of VA’s VISN 20 (Veterans Integrated Service Network #20) Mental Illness Research, Education and Clinical Centers program (MIRECC). "If you get the nighttime symptoms under control, veterans feel better all around."

While a wide variety of events can trigger what's called post-traumatic stress disorder, this PTSD blog focuses solely on the combat-related variety.
As a new generation of warriors returns to civilian life and seeks out resources, PTSD Combat is here to help.

Considerable Quotes

"The first shamans earned their keep in primitave societies by providing explanations and rituals that enabled man to deal with his environment and his personal anguish. Early man, no less than we, dealt with forces that he could not understand or control, and he attempted to come to grips with his vulnerablity by trying to bring order to his universe." -- Richard Gabriel in No More Heroes

"War stories end when the battle is over or when the soldier comes home. In real life, there are no moments amid smoldering hilltops for tranquil introspection. When the war is over, you pick up your gear, walk down the hill and back into the world." -- OIF vet John Crawford in The Last True Story I'll Ever Tell

"After wars' end, soldiers once again become civilians and return to their families to try to pick up where they left off. It is this process of readjustment that has more often than not been ignored by society. -- Major Robert H. Stretch, Ph.D in Textbook of Military Medicine: Vol. 6 Combat Stress

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